The program is divided into four phases: maximal protection, moderate protection, minimal protection phase and return to activity/maintenance.
In the first phase, the maximal protection phase; goals are to
1) Achieve early protected range of motion
2) Prevent quadriceps atrophy, and
3) Decrease pain and effusion.
The treatment consists of ice, compression, elevation and a brace that will allow full non painful range of motion.
In addition, crutches are used for the first few days for protection and weight bearing as tolerated. Immediately following the injury, aggressive supervised physical therapy is initiated aimed at retarding muscle atrophy and restoring full range of motion. Electrical muscular stimulation is used to re-educate the quadriceps muscle and also to retard quadriceps muscular atrophy.
Range of motion exercises are initiated immediately using passive and active assisted range of motion and then progressing to active range of motion. The purpose of the range of motion exercises are to re-establish normal range of motion and also to allow proper alignment of newly synthesized collagen tissue.
This ensures strong elastic scar formation. Other advantages to early motion include retarding capsular contractures, maintaining articular cartilage nutrition, and decreasing disuse effects. By the end of the first week, more aggressive strengthening exercises such as mini squats, leg press, and quadriceps eccentrics can be initiated.
The patient who has nearly full range of motion, minimal tenderness, and no change in instability or swelling can progress to phase 2, the moderate protection phase. The goals in this phase are to regain the remaining range of motion, achieved unrestricted ambulation without assistive devices, and restore muscular strength, power and endurance.
The emphasis of this phase is strengthening. More aggressive strengthening exercises are begun ( Isokinetic, heavy progressive resisted exercise, and also a pool running program).
In addition, flexibility and Proprioceptive training are emphasized. The progressive resisted exercise program for knee extension must be monitored for pattelofemoral joint irritation, crepitation and pain. If this occurs the program must be modified to a range that is pain free and crepitus free to prevent further articular cartilage breakdown.
The next phase of the program is the minimal protection phase. In this phase the goals are to increase strength, power and endurance and to improve neuromuscular coordination. The emphasis is now on functional return and the exercises are geared toward function. A running program is initiated as well ashigh-speed exercise. Agility drills, balance drills, and endurance bouts are used. In this phase we emphasize functional exercises in the closed kinetic chain.
The final phase, return to activity and maintenance, is initiated once the patient fulfills specific criteria. The patient must present with no pain or tenderness, no instability, an Isokinetic test that fulfills a specific criteria,and a satisfactory clinical examination. An athlete who obtains these parameter scan return to sport training and begin a maintenance program.